Wednesday, January 22, 2014

SIDEBAR: Strub says safer-sex messaging is more complicated than we think

by Chuck Colbert

While Sean Strub’s confessional and historical memoir “Body Counts” raises awareness and prompts important questions about HIV/AIDS prevention and treatment for men who have sex with men (MSM) and the larger LGBT community, one thing seems absolutely clear: Younger MSM view the epidemic through a different lens than baby boomers and seniors.

During a recent interview, Strub discussed the changed landscape of the epidemic and the implications for safer-sex messaging. “The truth is that the consequences of HIV exposure and transmission are very different today than they were 25 years ago,” he said over the telephone. “Younger people look at [HIV/AIDS] through the present reality, not the historical one.”

In criticizing fear-based messaging, Strub said, “The messaging too often has been either HIV is the most horrible thing that can happen in your life, your life is over; or it’s no big deal at all, just take a pill.”

Neither of those approaches, he said, is “quite right.”

“The focus should be that acquiring HIV is a life-changing event, it’s not a little thing, it’s a big deal,” said Strub. “There’s an expense — health and stigma issues — that are enormous; it is truly life-changing. But that doesn’t mean your life is over, or that you can’t be intimate, fulfilled and successful, just as people who don’t have HIV are.”

Strub also qualifies a mainstay of HIV-prevention messaging: Use a condom every time!

“In terms of condoms specifically, we’ve never been able to get more than about half of gay men at any given time to use condoms regularly,” he said, going as far back as 1989 when “the consequences were much more deadly then than they are for people today who have access to treatment.”

Strub was referring to any number of studies (http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6014a1.htm?s_cid=ss6014a1_w), including one released last year, which found that among MSM who meet sex partners through mobile apps like Grindr, 46.4 percent of those surveyed acknowledged having bareback sex, “always, often or sometimes,” at the same time 80.9 percent of respondents said they knew HIV transmission resulted from “unprotected anal sex, vaginal sex, and — less frequently — oral sex.”

Eighty-four percent of respondents said they barebacked because “with condoms, [sex] does not feel the same,” while 73.8 percent attributed unprotected sex with “impulsive sexual behaviors.” Men from Australia, South America, Europe, the United Kingdom, Canada and the U.S. participated in the study, which had a sample size of 725 gay and bisexual men. There were 498 U.S respondents, representing three quarters of those surveyed.

A better HIV prevention strategy, in Strub’s view, isn’t about focusing on just condoms or just on biomedical prevention, but points to accurate medical and scientific knowledge to enable better-informed risk analysis. “There are many ways to reduce risk, and gay men have always found their own path,” he said, “We need to make sure they have information that is accurate so their risk-analysis is more effective.”

“Quite frankly, having an undetectable viral load possesses a lower risk of HIV transmission than just using condoms,” Strub explained, readily acknowledging since there is a failure rate for condoms, “That’s hard for people to wrap their heads around.”

But that failure rate is a far cry lower than the 50 percent suggested in the late 1980s by the late Cardinal John O’Connor of New York, said Strub. “Most of the credible studies” point to a “failure rate between two and nine percent. Failure rate has a lot to do with how aggressive the intercourse is.

“So while there is a failure rate in condoms that result in HIV transmission, so far no one has even proven sexual transmission of HIV from someone known to have an undetectable viral load at the time of the sexual contact— not a single documented instance.”

Strub is not, however, saying don’t use condoms. “There are lots of good reasons to use them, including the fact that they do protect against many other harmful sexually-transmitted infections, and just because someone says they are undetectable doesn’t necessarily mean they are. For people who are HIV negative, condoms are cheaper than and don’t have the side effects caused by taking anti-retroviral treatment prophylactically (PrEP).

“And some people will not or cannot use condoms and for them, it is important they have access to PrEP, as well as understand measures they can take to help reduce their risk of HIV transmission.”

In chapter 30 of “Body Counts,” entitled “Barebacking,” Strub mentions other risk reduction strategies gay men have employed, with varying degrees of success, such as “sero-sorting,” which means having sex only with partners of the same HIV status, and “sero-positioning,” which means topping only if HIV-negative, bottoming only if HIV-positive.

True enough, as AIDS activist and blogger Mark King (www.MyFabulousDisease.com) reminds: “Condom use will almost certainly continue to decrease in the future because of new tools that have joined the growing list of HIV prevention options,” he wrote in “Your Mother Liked It Bareback” (January 28, 2013).

Those new tools include pre-exposure prophylaxis, or PrEP, which entails taking medication before having sex with an infected partner, or post-exposure prophylaxis, or PEP, which requires taking two to three doses of anti-retroviral medication within 72 hours of possible exposure to HIV.

Another tool in the future is rectal microbicides, which would come in the form of lubricants or douches, preventing infection.

Meanwhile, biomedical advances, including protease-inhibitors of the mid-1990s, have resulted in people with HIV living longer.

And while there are side effects to anti-HIV medications, “The short-term effects are vastly improved from years ago,” said Strub. “From my experience, most people diagnosed today who go on treatment do not experience any significant tolerability issues in the short term,” although that “varies somewhat by treatment. But that is very, very different from years ago.”

Nonetheless, long-term side effects remain unknown. “I am someone who often talks about how much we don’t know,” Strub said, referring to “what it means to take [anti-retroviral] drugs for 20 years, what it means to take these drugs in combination with other medications, whether anti-depressants, statins or anything else. We will find out in time, but right now there is much we don’t know. I think it’s important for people to understand that.”

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